[00:00:01] Speaker A: Welcome to a special edition of the Healthy you podcast. I'm Frankie Myers, your host, and today we have a unique episode lined up just for you. We are diving deep into the often misunderstood and sometimes challenging phases of perimenopause and menopause. Joining us is a distinguished panel of experts who will share their individual insight, experiences, and tips on navigating this significant stage of life. So grab a cup of tea, get comfortable, and let's embark on this journey together. Stay tuned. You won't want to miss a minute of this episode.
Perimenopause and menopause are often one of the most significant and often misunderstood phases in a woman's life.
Each woman may experience their own set of challenges and changes during this time. Whether you're experiencing menopause transition symptoms yourself or you're supporting someone you love, this information will help you to understand what's happening and what can be done so you can embrace this time with confidence and improve your well being. Joining us today are three of our riverside partners in women's health gynecologists who will share their insights and expertise to help you navigate the menopause transition and thrive.
First, let me introduce Doctor Casanova. Doctor Casanova earned her medical degree from Brown University Medical School in Providence, Rhode island. She completed residency training in obstetrics and gynecology at Northwestern University School of Medicine in Chicago. Doctor Casanova is board certified by the American Board of Obstetrics and Gynecology. Additionally, she is a certified menopause practitioner by the North American Menopause Society.
Next, we have Doctor Elizabeth Lunsford.
Doctor Lunsford earned her medical degree from Eastern Virginia Medical School before completing her residency at the University of Texas Health Science Center. Doctor Lunsford is board certified by the American Board of Obstetrics and Gynecology and she is too a certified menopause practitioner by the North American Menopause Society.
Also joining our conversation is Doctor Diane Medella. Doctor Medella earned her medical degree from Pikeville College School of Osteopathic Medicine in Kentucky and then completed an Ob GYN residency at Grandview Southview Hospital Kettering Medical center in Dayton, Ohio. She is board certified by the American Osteopathic Board of Obstetrics and Gynecology. Doctor Medela is a member of the American Osteopathic association, the American College of Obstetrics and Gynecology, the American College of Osteopathic Obstetrics and Gynecology and the Institute of Functional Medicine. Welcome everyone. Welcome. How are you ladies feeling? Fine. Great. I'm excited to have you here with me today. So, perimenopause, menopause and post menopause. There are so many changes that women go through or may experience during this phase of their life. Together, we will discuss everything from the hot flashes to hormone therapy to mental wellbeing, lifestyle modifications. Doctor Casanova, I'm going to start with you.
We have a personal relationship and I'm fine with conveying that. You are my gyn. Why is this phase of a woman's life so significant?
[00:03:43] Speaker B: Well, it's significant because it marks the end of a woman's reproductive years.
[00:03:49] Speaker C: Right.
[00:03:49] Speaker B: We spend many of those years being pregnant, having babies, raising children, and now we're suddenly launched onto this new phase of our lives, which may be mysterious and difficult.
[00:04:04] Speaker A: Absolutely.
[00:04:05] Speaker B: So I think that's part of why it's significant. And changes are happening in your body, just as you mentioned, you know, physical, emotional, that are all new, and we need to navigate those changes.
[00:04:18] Speaker A: Absolutely. And I don't think you always know what's really going on because sometimes we're in denial that we're even aging.
So, yeah, that's very helpful. Let's start by defining what we mean by perimenopause. Menopause and post menopause. Doctor Medela.
[00:04:36] Speaker C: So, I mean, I think there's a lot of confusion around this whole realm of menopause. Perimenopause women have no idea where they are. But the reality is it's a clinical diagnosis. Perimenopause and menopause is a clinical diagnosis. So we do have patients come in requesting hormones to be checked to see if they're in perimenopause. But you don't need hormones for that diagnosis. The diagnosis is based on the woman's age and based on her clinical symptoms. And as doctor Casanova said, it really is a reflection of declining fertility, and that's why these symptoms occur. So perimenopause is a reflection of decreasing ovarian function. Menopause is a physiologic reflection of. It's harsh, but ovarian failure.
And when I say ovarian function, we're talking about the secretion of three primary hormones, estradiol, progesterone, testosterone. So perimenopausal women's declining fertility will result in changes in those hormones, which is why they have the symptoms that they have in menopause. When that woman ovulates her very last egg, the definition of going an entire year without a period puts them at menopause. And menopause is one day the following day, they're officially post menopausal, and then they're postmenopausal for the rest of their life. So these are all technical terms, but this is the physiology of why this occurs.
The average age of menopause in this country is 51 52.
Perimenopause can occur typically. Symptoms can start anytime after the age of 35. That's typically when we start to see that decline in fertility.
But most women are symptomatic, typically in their forties. In their forties, although we can see it as early as 35.
[00:06:27] Speaker A: Okay, that's helpful.
[00:06:28] Speaker C: So, premature menopause is when your ovaries fail before the age of 40, which can happen for various reasons, but it isn't very common.
Early menopause is when women's ovarian function fails before the age of 45.
And there are a lot of reasons why that happens also, which we'll get into later.
[00:06:52] Speaker A: Just for myself and my own personal experience, it's not something that women talk about a lot to each other. I do know what I overheard growing up. Sometimes when you're privy to conversations that you shouldn't be, is it true that you may follow whatever your mother's pattern was as it relates to when you go into perimenopause? Menopause. And is there any association with early menstrual cycles and the timing that you will experience perimenopause? Menopause?
[00:07:21] Speaker C: Yeah, you know, so early menarche, so the earlier a child starts her menstrual cycle does put her at risk for earlier menopause.
Nulliparous women, women who have never had a baby, are also at increased risk for earlier menopause. And the reason being is they don't have a break in that ovulation cycle, like women who become pregnant or women who start their menstrual cycle later in life. And so women are predetermined and born with a certain number of eggs. And once you exhausted those eggs, typically determines when you go into menopause. So those are some associated risk factors for earlier menopause. And some women also will form or will follow their mother's trend. We see that, too, although other environmental factors can play a role.
[00:08:11] Speaker D: Surgery.
[00:08:12] Speaker C: So women who have their ovaries removed for pathologic reasons will go into surgical menopause.
But even women who have had a hysterectomy and their ovaries are left behind are at higher risk for early menopause.
And women need to be aware of that. So when they come in demanding that hysterectomy they have to understand that there is a risk that they may go into menopause and have perimenopausal symptoms much earlier than they would if the uterus was left behind. And current data supports that it can be up to five years earlier if they have their uterus removed, even if ovaries are left behind.
[00:08:52] Speaker A: Great information.
[00:08:54] Speaker D: I think the three biggest things I see in clinical practice that I ask patients about would be the surgery, the history of the surgery. Because, as Diane was mentioning, it's very important, the blood flow to the ovaries from the uterus. Tobacco use is really important, too. So we see, on average, women going to menopause about four years sooner if they use tobacco.
And then also the family history. That's really important, too. So, mother, sister, those are the biggest things. But I will say, if you remove the fallopian tubes, actually, there's not a higher risk of going into menopause in the studies that are out there. So it's okay to take out the fallopian tube connection, which we commonly do now for sterilization. It's just more removing the whole uterine body that can affect the ovaries.
[00:09:37] Speaker A: Very helpful. Very helpful.
This time can be very challenging and confusing for a woman.
Some of the changes may happen gradually or, you know, even more quickly. So how do you start to recognize that you're in perimenopause? And I'm going to ask Doctor Lunsford to talk a little bit about that.
[00:10:00] Speaker D: Sure. I like the definition of menopause is puberty in reverse. And a lot of women, it's been about 40 years since they've been in puberty, and they start to experience those fluctuations. Like doctor Medella was saying, the hormones can really fluctuate throughout the month, and those can start to cause symptoms in their body that they're not used to experiencing. And it can start many years before the final, last menstrual period.
So I think thinking of it in that way, that, you know, you're thinking about your body going into that phase, and that starts to produce all sorts of symptoms that we'll get into talking about much more than just hot flashes, but it can start to produce vaginal dryness, mental health changes, joint pain, things that people aren't commonly thinking, oh, this could be from menopause. But also, women spend about a third to a half of their life in menopause. So I think it's also important to understand your body will fluctuate throughout that period. But there's a way that you can have a good menopause and we don't have to necessarily think of it as a gloom and doom. Like, oh, no, I'm going into this next phase because, you know, some women say it's kind of a calm after the storm, after they get through that transition period. And I think the more we have a good mindset about it and optimize our health, the better we can embrace that transition and have a good, good menopause. Actually, there's a u shaped curve to happiness. If you look at across studies, across multiple countries, people are, tend to be happy in their twenties. And then it goes down, down, down till around 47, and then it starts to come back. It does, you know?
[00:11:37] Speaker A: Yes.
[00:11:37] Speaker D: So there's a lot to embracing that. Like, my life could get better, can get better, especially if I take good care of my health. That just happens. All in that forties is when you're raising children, you know, sometimes caring for older parents, and then your body starts to rebel and go through this reverse puberty, and you're like, what's happening?
[00:11:57] Speaker A: Right, right. That's a great point. And you touched on this a little bit. Sometimes as women, we're taking care of everybody else. So we're moms, we may not be moms, we're taking care of parents, we may not. We have jobs. And you may not really understand what's causing all of your stress, anxiety, frustration and just emotional changes.
[00:12:19] Speaker D: Absolutely. Which. Yes, absolutely. A lot of the patients come in and say, I feel like I'm going crazy. I mean, we hear that a lot in clinic, and that's, you know, certainly those hormonal fluctuations affect your mental health, but we try to reassure them you're not going crazy. You know, these are, some of what you're feeling is just a result of these hormonal fluctuations that you're experiencing.
And that can be reassuring.
[00:12:44] Speaker B: I actually had a patient yesterday who was describing it. She was perimenopausal and describing the changes. And she said, I feel like I'm unhinged.
[00:12:54] Speaker D: Wow.
[00:12:55] Speaker B: I thought that was really interesting.
[00:12:57] Speaker A: Yes, yes.
[00:12:58] Speaker B: You're still connected, you're still swinging and functioning, but you're a little unhinged.
[00:13:05] Speaker D: That's a great way to put it.
[00:13:07] Speaker A: Yes, absolutely.
[00:13:09] Speaker C: I mean, perimenopause really is like the PM's that never ends. I mean, it's physiologically very similar, but PM's ends when you have your menstrual cycle. And perimenopause, it's this constant. The hormones are, and specifically estrogen. So I mean, that's why the symptoms are so severe. It doesn't stop until that menopause date arrives. And so it's a prolonged suffering for a lot of women, but they just need to understand why they're going through those. And if they can understand it and make correct choices, whether it be through hormone replacement therapy or lifestyle changes, they can get through it. And as doctor Casanova said, the other side is much better.
[00:13:53] Speaker A: And being open and communicating that to your support group, they'll understand. They'll be more understanding, I think, because sometimes they don't know what's going on either. They think you just, you're just being grumpy. Yeah.
[00:14:08] Speaker C: Yeah.
[00:14:09] Speaker D: And there's a spectrum of people, too. There's some patients we have that go through that transition and they barely have a hot flash. And they're like, I'm good, you know, and sometimes it can be because they're being treated with other medications they don't realize. But anyway, some women transition through that. Like I'm saying, if they're on, for instance, one of the treatments that we'll get to later is like anti anxiety medication. So they're already on that. They might not experience as many hot flashes, but still some women transition through that and they really don't experience a lot. And then you have other women that are having sleep disturbance, fighting with their husband, can't focus at work. I mean, just having every symptom in the book. And so there's a wide spectrum and range of patients here, too.
[00:14:53] Speaker A: Absolutely.
[00:14:54] Speaker B: And some women do recognize triggers. You know, anxiety or stress can certainly trigger vasomotor symptoms. Alcohol for some women, definitely is a trigger. Hot spicy food. So some women, like, at least recognize the triggers. You can't always control them, but at least you can recognize them. But as Doctor Lunsford said, yes, it is very variable. It's amazing to me that some women do float through it without any major symptoms. But I think sleep disturbance that Doctor Lunsford mentioned, I think that is one of the, what I see in my clinical practice is what pushes a woman to seek treatment is I'm having these hot flashes, night sweats, and I can't sleep. My sleep is interrupted. Then I don't sleep well. I'm trying to go to work the next day or take care of my family, and I'm grumpy and I'm moody and I'm craving carbohydrates and I'm sleepy.
[00:15:55] Speaker A: Yeah.
[00:15:56] Speaker B: So I think that's a big motivator, is the sleep. And we know how sleep, how important.
[00:16:01] Speaker A: Sleep is for our health, on everything, on your weight gain, if you're not sleeping properly as well, talk a little bit about the bladder issues and the urinary issues that women experience.
[00:16:14] Speaker B: Sure. So, you know, our bladder has estrogen receptors, so it responds to estrogen. So when we start having declining levels of estrogen, things change. And sometimes it's a later manifestation of menopause, but not always. So women will have feelings of frequency, urgency from their bladder, from lack of estrogen.
The term genital urinary syndrome of menopause specifically relates to the changes that happen in that area related to lack of estrogen. And the good news is there's very effective, safe medications that we can use.
[00:17:02] Speaker A: To those help with that. You know, my mom's not a doctor, but they know everything. Old remedies, is this something that the Kegel exercises can help with or will. Will not, like, build in the strength or muscle tone of that pelvic floor or not in this case, medication is the ill. I think that's what she told me.
[00:17:22] Speaker B: That's more for urinary leakage.
[00:17:24] Speaker A: Okay. Okay.
[00:17:25] Speaker B: Which can be associated with menopause, but not necessarily.
[00:17:29] Speaker A: Okay.
[00:17:30] Speaker B: Yeah, but I'm talking more about those, like a woman whose bladder is fine until they start to experience low estrogen and they have more frequency, urgency, vaginal dryness, painful intercourse, those are things that are specifically related to estrogen.
[00:17:45] Speaker A: Okay, thank you for clarifying that.
[00:17:47] Speaker D: That will typically come, like Doctor Casanova saying, about three to five years after the last menstrual period. Everyone's a little different, but we certainly see that in clinical practice, like three to five years later after menopause is kind of the peak of when we see patients coming in with also recurrent urinary tract infections is another big one.
Yeah. Nocturia, urinating at night.
[00:18:08] Speaker A: Yes.
[00:18:09] Speaker D: And unfortunately, there are really good, like she was saying, safe, effective, and affordable treatments now, because a lot of these products now have generics. So it's good that there's good treatments out there.
[00:18:21] Speaker A: Good. Very good. Doctor Medela, we're going to pick up on the conversation and share more about symptoms. So we're going to talk about. I've already alluded to the weight gain, which is something I know a whole lot about. I just got rid of some things. Cause I moved. I never will be a size 2468 or ten again, and I don't feel like I eat a whole lot. But after hitting a certain age, it's harder to get the weight off after menopause. So talk a little bit about that. We've already talked a little bit about some of the things that are going on vaginally, but talking about the atrophy.
[00:18:59] Speaker C: I think one of the number one reasons women come in and complain is this weight gain that most women will see. The distribution of fat will change from their thighs and their buttocks to their abdomen.
With declining hormones comes a change in metabolism that's directly related to your sex steroid hormones, estrogen, testosterone. So the weight gain is real, and it's real because women don't understand that their metabolism has changed because their hormones have changed. And some women see it. A lot of women will see it right after childbirth. And once again, so when women breastfeed postpartum, they are really in a state of menopause where their estrogen is suppressed. And so that is why metabolism is also altered there. Now, the breastfeeding does help with the metabolism there, too, but women will say, after I had my second child, I wasn't able to keep the weight off. And then the same is kind of similar in the perimenopausal period. It's that transition, that hormone change, that really affects a woman's ability to metabolize, really, glucose. Glucose tends to be the culprit in most of this, or carbohydrates as we know it in the diet.
So the weight gain is real, and women have to stop berating themselves about it, because the truth is you aren't doing anything different. And yes, you're gaining weight, but the reality is you do have to do something different not to gain the weight because your hormone levels are changing because of that. Your ability to metabolize efficiently is what associates the weight gain.
[00:20:40] Speaker A: I think it's highly unreasonable to never take in another carb.
[00:20:44] Speaker C: Oh, yeah. I mean, we need carbohydrates. The problem is, is we're consuming the wrong kind of carbohydrates. And that's in all ages. It has nothing to do with menopause. I mean, that's every age, you know. And so the RDA recommendation for carbohydrate intake, and this is just for basic metabolic function and to keep your organs, you know, functioning properly, is 130 grams a day. The average american consumes greater than 300 grams of carbohydrates a day. And what does the body do with excess carbohydrates? It gets stored to fat. And in a menopausal woman, it really.
[00:21:17] Speaker D: Gets stored to fat.
[00:21:18] Speaker C: So, I mean, you have to understand the physiology of menopause and perimenopause. And why what you ate ten or 20 years ago doesn't work for where you are at this stage in life. And so you really have to understand that to make the change.
[00:21:36] Speaker A: You women are great role models because you look fabulous, so you're doing something right. So a lot we can learn from that.
[00:21:43] Speaker C: I think one thing I do want to mention, there are those classic symptoms that we associate with. With menopause, obviously, the hot flashes, the night sweats, the weight gain. The reality is there are estrogen and progesterone receptors in every system of our body. So we forget that we have estrogen receptors in the brain. We forget that we have them in the gut. So I think the real question is, what symptom doesn't a perimenopausal woman have? Because that decline in hormone affects every system in the body. And I think that's where some of the gaslighting comes, is that. And this is. Practitioners are guilty of it. Patients are guilty of it because they don't even realize that their symptom may potentially be related to menopause or perimenopause. So I think now that there's more awareness, actually, Duke University did a study in 2022 kind of linking this association.
There's something called frozen shoulder. I don't know if anyone here has ever had it, but I've had it, and it's horrible.
And the medical term is adhesive capsulitis, which is inflammation of the glenohumeral capsule.
But what, you know, it tends to be more common, two times more common in women, and classically occurs in women between ages 40 and 60.
So the department of Ob GYN and the orthopedic department in Duke got together because of this correlation, and they actually did a retrospective study on 2000 post menopausal women, and they actually found that women that were on hormone replacement therapy had a less incidence of frozen shoulder.
[00:23:22] Speaker A: Wow.
[00:23:23] Speaker C: And frozen shoulder. And musculoskeletal symptoms of menopause is more common in asian women. Surprise, surprise. And in Japan, it's actually the most common menopausal symptom in japanese women in the country of Japan. So I'm not saying that you need to start hormone replacement therapy to prevent frozen shoulder, but, you know, there are those. You know, there is that correlation. Whether or not it's causation, we still don't know. So more study needs to be done. But I think because of this awareness, people are actually looking at other symptoms that could be associated with menopause and perimenopause, because there really is some kind of correlation going on there.
[00:23:55] Speaker A: Absolutely. Great information. Yes.
[00:23:57] Speaker D: One other thought, Frankie, just while we're talking about the weight gain, again, I think the mindset's really important. And there's actually one theory that you don't want to be too thin in menopause because that really can increase your risk, osteoporosis. So they've studied and said, like, you really did. I mean, they just picked a number in the study. But women that weigh less than 127 pounds have much higher risk of osteoporosis and thinning of the bones. And so when you're a little bit heavier, that actually produces some estrogen that helps to protect your bones. So one of the theories is that when you go through menopause, your body's actually trying to protect you against that future menopause, should you live to 80 or 90 years old. So, again, just understanding that your body might be just trying to protect you and what's really important.
Right, exactly. And what's more important than just the number on the scale is really, like we were saying, where is that weight distributed? And the most dangerous weight distribution is the visceral fat around your organs. So we can talk more about that. But again, just embracing that, yes, my body probably will not stay the same as when I was 25. Your internal view of yourself will probably stay the same, but your body might change a little bit, and it might be trying to help you for down the road.
[00:25:11] Speaker C: Yes. That distribution is supposed to be an evolutionary advantage for us, because when the ovaries fail and no longer make estradiol, estrone kicks in, so that the ovaries make a little bit of estrone. But estrone comes predominantly from adipose tissue. The problem is we have too much adipose tissue, which works in the opposite direction. So instead of being protective, it becomes inflammatory.
[00:25:36] Speaker A: So you don't have to lose it all.
[00:25:37] Speaker C: You don't have to lose at all.
[00:25:38] Speaker A: That's good, too.
[00:25:39] Speaker C: A little bit of cushion is actually healthy.
[00:25:42] Speaker A: Okay, good. Great information.
[00:25:45] Speaker D: And the last symptom I'll touch on we do here is feeling dry, feeling like skin changes, the hair thinning. Women start to notice hair, hair in places they haven't before, but just dry eyes. So, again, as Doctor Medella said, there are estrogen receptors in many, probably all tissues in your body, and you might start experiencing that in different ways that you haven't before.
[00:26:10] Speaker A: That hair problem is the biggest concern for me, and my grandmother had the.
[00:26:16] Speaker C: Same thing, and so it's that imbalance of the hormone. So as that estrogen's starting to decline, the testosterone is still there and so that testosterone is more prevalent and that's where the hair growth will come in typically if it's related to menopause.
[00:26:31] Speaker A: Yes.
Well, I didn't have it before, so I'm correlating it with menopause.
All right, just great information. You're dropping some great pearls.
Whether you're experiencing one or any of the combination of these symptoms, it is important to know that you do not have to deal with this alone. It doesn't have to be your new normal. And there's many things that you can do to improve the health and quality of your life, I think is what's optimistic about this conversation as well. So let's talk about controlling the controllables. I like that the CC's and where your health provider can partner with you to support you during this phase. I know that I value having a relationship with my gyn and primary care. Not everybody has that some use, you know, you know, urgent cares and other avenues of getting care and don't have that consistency. And I think sometimes things can be missed because you don't have that relationship and rapport.
So let's talk a little bit about Doctor Casanova, about managing weight changes during this time. And you know, just bringing some of your experience with this to the table.
[00:27:52] Speaker B: I hope it doesn't sound like doom and gloom, like you're destined to put on 40 pounds at the time of perimenopause.
So we do have some control over it. And I think Elizabeth can maybe speak to more of the structured exercise. But certainly there's things that you can do to increase your baseline metabolism. Like doctor Medela was talking about, you know, take the stairs, not the elevator. Park your car farther away from the entrance at target or Walgreens, and do that extra walking. You know, we do. Unfortunately, even though we think everything's the same, we do decrease our activity as we get older. So I think we have to make that extra effort to increase the day to day activities that can keep us moving.
[00:28:41] Speaker A: Agreed.
[00:28:42] Speaker B: Exercise, I think is good for everything. I can't think of other than joint pain.
[00:28:49] Speaker A: Maybe I was gonna bring that.
[00:28:51] Speaker B: I don't think there's anything that exercise doesn't benefit.
[00:28:54] Speaker A: Yes, and it may change to your point. You can't do some of the things you did when you were younger. I know you end up hurting yourself. So age appropriate exercise is a good point as well. Did you want to add something as well?
[00:29:09] Speaker D: Well, I just think it's good to do a mix of exercise. So there are guidelines out there saying, like trying to get some aerobic exercise, like about 150 minutes a week of moderate intensity exercise or at least 75 minutes of vigorous exercise. But I usually tell people, you know, 150 minutes a week. So that's 30 minutes a day for about five days a week. And then strength training is really important. Again, especially in this period of life, you tend to, as your testosterone levels go down, you tend to be more prone to lose muscle mass. And so really incorporating at least 20 minutes of strength training, ideally three times a week, is very important. And then I think flexibility is really important, too. So doing things like yoga, stretching, pilates are good for your pelvic floor, you know, so whatever way an exercise can be a reward as well. It doesn't. Again, the mindset is really important and figuring out how it's going to, just how it's going to work into your day in the smoothest way. So a lot of my stay at home moms have peloton and they do peloton workouts at home.
Some people exercise with friends after work.
Bike riding is my favorite. But then again, I still try to do some strength training in with it and try to mix it up and try, if you're doing something that hurts, you probably don't want to keep doing that. There's a difference between hurting your joint and feeling sore muscle soreness. And you need to be in tune with your body enough to know where that level is. But that is really, really critical for your long term aging and helping prevent the osteoporosis. And a lot of things we mentioned and the visceral fat, I was mentioning that before. I think one of the best things people can do is to purchase a scale on Amazon. They're only about $40, but it'll send out impedance signals through your body and it will give you, it'll chart on your iPhone, like how much visceral fat you have, how much subcutaneous fat you have, how much muscle mass you have, how much bone density you have, or how much bone mass you have. So that's nice, because then you can plot it. You don't have to check every day. You can just check once a week or once a month. But that's much better than just seeing a number on the scale because the number on the scale could represent how much water you're retaining. Again, if you're pmsing at that point, you retain more water.
Yeah. So I think those scales are easily accessible and available to people now. And the visceral fat is really what is going to increase the risk of diabetes and heart disease. It's actually biologically active. Like doctor Medella was saying, a lot of adipose, or fat tissue, produces hormones, and the tissue around the internal organs produces the wrong kind of hormones, like the ones you don't want that are going to make you hungry, that are going to put you more at risk of diabetes.
So that's why I think those scales are really a great tool for people to see where their health is at.
[00:32:02] Speaker C: That's very helpful. More data supporting body composition as a real reflection of true health. I mean, I think BMI is going to be antiquated here probably in the next few years.
[00:32:12] Speaker A: Cause it keeps going down. So that's helpful.
[00:32:14] Speaker B: It was 35 years ago.
[00:32:16] Speaker A: Now, unless you're asian, 28, 25, 28.
[00:32:18] Speaker C: Unless you're asian, then you're overweight. If you're BMI's 22, but I think it's like 23, you're overweight if you're BMI is 23. If you're Asian. It's so wrong. But no, but body mass. Cause you can see a skinny woman, but if you actually do her body mass composition and her visceral fat is high, she may look healthy, but technically she really isn't because of the changes in the inflammatory cytokines that occur with visceral fat. But I think if women want to invest in. Because to exercise alone is always the task for most people. But I think the biggest investment menopausal and perimenopausal women can do is in their muscle. That is probably the most efficient way women can combat the declining metabolism. So muscle is probably, I think, is the largest. I mean, it's biologically active, but it's a metabolic sink, so it functions in the metabolism of glucose and fat. So the more muscle you have, the more insulin sensitive you are. And that's the biggest battle in perimenopause and mental menopause is the insulin resistance. And we all become insulin resistant as we age. But women kind of take this huge leap of insulin resistance between perimenopause and menopause, and it's that decline in hormone that causes that. So strength training is so essential. I mean, the reason why people end up in nursing homes is because of frailty.
[00:33:50] Speaker A: That's a good point.
[00:33:51] Speaker C: Frailty and immobility. So that's another reason why you have to focus. Focus on your muscle. You know, you don't have to end up in a nursing home. If you have strong muscles, you're gonna have strong bones, so it all kind of goes hand in hand. But if you're really looking to increase your metabolism, muscle, you know, being strong, being active, building muscle, maintaining muscle is really where it's at, especially as you age.
[00:34:16] Speaker B: That's great.
[00:34:18] Speaker A: Doctor Medela. I want us to continue to talk a little bit more about controlling the controllables. We've talked about some of the changes as it relates to weight.
What are some recommendations from that perspective? And let's dig a little deeper into some of the nutrition aspects that can help build muscle tone, etcetera.
[00:34:38] Speaker C: So we already talked about the importance of muscle.
We all lose muscle mass as we age. It's just a part of the natural aging process.
We lose about three to 8% of our muscle mass per decade after the age 30, and that accelerates up to five to 10% of muscle mass per decade after the age 50. And menopausal and perimenopausal, women tend to see that rapid decline in muscle strength and muscle tone. So unless they're doing something proactive about it, like strength training. But one of the more essential components of the diet to help promote muscle and maintain muscle is protein.
So protein is, we make protein, our body makes protein, our body needs and makes up to 300 grams of protein just to maintain our organ function, our physiologic cellular function. So if you're not consuming enough protein, your body actually breaks your muscle down for protein. So that's why your protein intake is so important. And there are some controversies on what is considered adequate. The RDA recommends for women up to age 50 point, I believe it's 0.8 milligrams per kilogram. 2.2 kg is one pound. But for a menopausal perimenopausal woman, and you have to understand that these are nutritional guidelines.
Most of these guidelines are meant for sedentary populations. So you really have to look at the individual to determine truly what their. Their protein or their carbohydrate you have based on their activity, based on their age. But the likelihood is, though, as we age, we do need more protein and we need quality protein.
Proteins are amino acids, right? So there are 20 amino acids. Nine amino acids are essential, meaning you have to get them in your diet.
And really, animal protein is really the most complete protein, where you get all nine essential amino acids. And so I know there are vegetarians out there, and vegetables have definitely their place, too. But unfortunately, vegetable based proteins are deficient in three of the nine essential amino acids. And those three essential amino acids that are absent in vegetable protein are so critical for muscle maintenance and synthesis, protein synthesis. So protein's very important. A more recent meta analysis, looking specifically at post menopausal women made a recommendation of 1.5 milligrams per kilogram. And if a woman is very active, that rate could even go up to 1 gram per pound of ideal body weight. But if you're starting out obese, you have to once again look at the individual and your requirements and your nutritional recommendations are going to be based on that individual. And these are just guidelines. Absolutely. But so protein is going to help protect and maintain bone instead of your body breaking it down. So that's why the diet portion is extremely important.
[00:37:43] Speaker A: That's very helpful. Very, very helpful.
[00:37:46] Speaker B: You meant muscle.
[00:37:49] Speaker A: Butt muscle. Yes, yes, yes, yes, yes.
[00:37:52] Speaker C: Your body will break down muscle if you don't consume enough protein.
[00:37:56] Speaker B: And the more muscle you have, the better bones.
[00:37:59] Speaker C: Yes, bones you have.
[00:38:00] Speaker A: Yes, yes. Because sometimes as we age, you do start to potentially at some point you start losing weight. And you can tell sometimes when you don't have that muscle tone as you age.
[00:38:12] Speaker C: Yeah. You're not consuming enough protein.
[00:38:13] Speaker A: Exactly. Yes, absolutely. Doctor Lunsford, touch a little bit on how you metabolize alcohol differently during this time?
[00:38:25] Speaker D: Yeah, that's a great question.
So going back just a little bit to the nutrition, the most common question I get in, well, woman checkups is what kind of diet should I follow? What should I be eating? What kind of food should I eat? And the body's incredible that it can eat such a wide range of foods. And we have a wide range of foods available to us. So I usually tell patients really to focus on whole foods, anti inflammatory foods, mediterranean style diet, because there really is a lot of research about the mediterranean style diet helping to prevent heart disease. Personally, I try to get two vegetables and one protein with every meal. So, like, planned portions of plants and proteins. So if you just try to do something simple and think, like, okay, with breakfast, I want to get, you know, an avocado, eggs, and some spinach, you know, you're done. Lunch, salad, some salmon, some chicken nuts, you know, other vegetables, you're done, you know, and then dinner, meat, two vegetables, and then you can add a little bit of carbs in here and there. It's not the end of the world, but just trying to simplify down. The more healthy food you eat, the more your body will start to feel satisfied and feel full and have enough nutrients and minerals. Because some. There's also theories about the reason we're overeating and getting obese is because our bodies are actually lacking some of these critical nutrients, because we tend to eat very calorie dense, but nutrition poor foods. And so, again, just going back to, you know, trying to cook at home, eat at home, eat whole foods, that can really help your health.
So the mediterranean style diet focuses a lot on those vegetables, protein sources. It does say that you can drink one to two glasses of wine a day, but that's probably not the best for women's health, especially for women that are post menopausal. Because alcohol can definitely increase your risk of breast cancer. It also can increase your risk of osteoporosis. It can make it very difficult to lose that central fat. So some women, it can really put fat around the center. It can also increase the sleep disruption. So some women, there's kind of that drink a glass of wine while you're making dinner, but that's probably, like, the worst thing you can do for your sleep that night. So you really have to be aware of, again, how is what I'm taking into my body, how's that going to affect my night's sleep and affect my long term health? So it used to be that women, it was recommended no more than seven drinks a week, but now they've lowered the guideline down to no more than two. And even at two, it's probably impacting your health at some level, again, taking into consideration your family history and all these other factors with that personalized, individualized medicine. So I'm not saying never drink, but I'm just saying there is a lot of, there can be some consequences to your health if you're drinking a significant amount of alcohol. And really, it's supposed to be only about two drinks a week or less.
[00:41:32] Speaker A: Wow.
[00:41:33] Speaker C: I find it curious that, you know, there's all this hoopla about hormone replacement therapy and breast cancer when the reality is, is two glasses of wine a day actually has a much higher risk of breast cancer than hormone replacement therapy.
[00:41:47] Speaker A: Oh, my goodness.
[00:41:48] Speaker C: No one's talking about that.
[00:41:49] Speaker A: No one's talking about that.
[00:41:51] Speaker B: Same thing with obesity. Right.
Increases your risk, risk of breast cancer. And nobody's saying that. They're more concerned about what is my risk from taking these hormones of breast cancer. So we kind of have to refocus what we're, and we don't want to.
[00:42:06] Speaker D: Take everyone's fun away. I mean, I realize can't have any cold.
Yeah. And actually weight loss, too. It's important to eat meals with your family and with friends as much as you can. That's actually one of the other important tips for weight loss. Trying to be part of a social network and eating your meals together can also help your health. So we realize, you know, we live in a society with a lot of different factors and our bodies can handle a lot, but we do have to take care of them. Consistent, good nutrition, good sleep, exercise, you know, the more we care for our bodies, the better they'll take care of us.
[00:42:40] Speaker A: Yes. Is there, what about timing? Like late night eating? Is there truth to that? Like after some say after sudden.
[00:42:48] Speaker D: Yeah, sumo diet. You don't want to be on the sumo diet. So, Sudo, sumo wrestlers, they eat a lot late at night. That's how they gain a lot of weight. So there's definitely truth to trying to fast for at least 12 hours. So, I mean, personally, I try not to eat after 07:00 p.m. and not till 07:00 a.m. the next day. And definitely eating late at night is not good for your metabolism. And if you even walk for two minutes, that will lower your risk of diabetes. So I think it's good to eat lunch, go for a little walk, even a five or ten minute walk, eat dinner, go for a little walk.
[00:43:18] Speaker A: That's doable. That's really doable.
[00:43:20] Speaker C: You're more insulin sensitive early, earlier in the day, you know, it's your circadian rhythm that you need to work with. So your circadian rhythm, your body slows that insulin as night comes, and that's why metabolism slows. So like doctor Lunsford says, I mean, ideally, the earlier you can eat dinner, the better.
So timing is important. That twelve hour break does a lot for the body. You know, as far as health maintenance, autophagy is a process that actually when you go prolonged periods of time, the body will cleanse itself of cells that are no longer optimally functioning. That's the process of autophagy. Women in menopause and perimenopause need to be a little bit more careful with prolonged fasting because that breaks down your muscle. And we already talked about and emphasize the importance of muscle. So it's kind of a fine balance and different things work for different women. But I think doing prolonged fasting in a menopausal or an older woman could be detrimental. So that you have to realize that.
[00:44:26] Speaker A: That'S very helpful, very educational for me, even though we're healthcare professionals, this conversation has been important for me to do some reevaluating myself. So thank you for sharing great information.
I am so glad you bring up hormone replacement therapy. Right.
Let's dispel some of the myths around this treatment and let's talk a little bit more about that. In 2002, the National Institute for Health, the NIH study that found HRT more harmful than beneficial for menopause women, leading women to avoid this suffering with side effects that could have been relieved with HRT.
More recent studies have found that HRT to be safe, effective treatment to reduce menopause symptoms in healthy women under the age of 60, key being within the first ten years of the last menstrual period. So let's talk about why hormone replacement therapy may help women both from easing symptoms to what we now understand may have many protective qualities as well. I think that's Casanova. Yes. Yes.
[00:45:39] Speaker B: Okay, so you were referencing the WHI study, and that was a study that came out in 2001, 2002, and it was designed not to evaluate menopausal symptoms. It was designed to see if menopausal hormone treatment could prevent chronic disease. So the women in that study were actually, on average, older women, average age, I think, was 63, 65.
And it looked at prevention of cardiovascular disease and breast cancer and stroke. And the volcano that blew up was when they discovered that the women that were on both estrogen and progesterone had an increased risk of breast cancer. Slight increased risk of breast cancer after five years or before five years, even compared to the women who are on estrogen alone, did not have that increased risk of breast cancer. And I think that got released by the media and really caused prescriptions for hormone replacement to plummet.
[00:46:55] Speaker A: I'm sure.
[00:46:56] Speaker B: Yes, did actually cause a lot of suffering in terms of symptoms of menopause. It was data that was collected over a long period of time. We kept looking at it. The thinking now is that if we look at the group of women that were studied and break them into age, it looks like women between the ages of 50 and 59 who were in that study did not have those increased risks associated. And the thought now is that that age group of women who were within ten years of menopause, in their fifties, probably the benefits outweigh the risks in terms of menopausal hormone treatment. I mean, we know, and we've known it for years, that estrogen is one of the best things to prevent hot flushes, night sweats, it's preventative for bone health. We've known that for a long time. But when we relook at that data from the WHI, we now have recognized a group of women that are good candidates to be treated with these hormones. That doesn't mean that anyone over the age of 60 should not be taking hormones or should not be on menopausal hormone therapy. But we have to reevaluate with each decade of life or each several years to decide what are the risks and benefits as the baseline risks go up, of getting coronary artery disease or a blood clot. Do we want to add to that risk with hormones? Is it time to wean off? So I think definitely the treatment needs to be individualized. We do have good medications to treat symptoms, and there are women who can still benefit from it.
[00:48:49] Speaker A: Absolutely. Absolutely.
Great information.
Doctor Lunsford, HRT can help treat symptoms like hot flashes. And we've talked a little bit about this already, night sweats and some of the vaginal atrophy that may occur. Can you talk a little bit about that for me?
[00:49:11] Speaker D: Sure. So we really want to get to the root of what symptoms the lady's having and what's bothering her the most before we can really talk about what the best delivery method for the estrogen or the progesterone will be. So that's where we start in our visits. We start what symptoms? How is it disrupting your life? How can we help you? If they're having primarily vaginal symptoms, then we'd like to use those lowest dose of vaginal treatment, because we just want to treat that symptom. We don't necessarily need to expose them to a larger hormone dose than what they need to help. So there are lots of treatments for the vaginal symptoms and the bladder symptoms that we're mentioning that are just applied topically. Some of those also can be taken orally, but actually will affect the vaginal tissue. And then if women are having more systemic symptoms, if they're having sleep disruptions, mood irritability, hot flashes, they would probably benefit more from what we call systemic hormone therapy. And that would be delivered typically either by transdermal, through the skin, or orally. And so there are lots of different combinations, formulations. That's why we like to have just a dedicated visit, just to go over those options with women, and then we bring them back. Typically, I like to see them back in a month or two if it's a new start of hormone therapy, to see how they're doing to adjust their medications. Certainly they can reach out sooner if they're having any issues. And then it's really important for them to see their healthcare provider once a year so that we can provide that personalized medicine to them and look at their specific health because there are certain conditions where women are not candidates for hormone replacement therapy, even if they fit that age range of ten years of the. And menopause. You know, not everybody is a candidate for hormone replacement therapy. And so certainly women that have had estrogen receptor cancer, we have to be very careful about that. We do sometimes still use vaginal estrogen because it's such a low, low dose, but we certainly would want to go over the risk benefits of that with them. Also, women that have had a previous heart attack or stroke or have known coronary artery disease, we have to be very careful about giving them estrogen because we don't want to cause them to have another heart attack, stroke or blood clot. So certain women really are not candidates for it. And that's why we want to see them back every year at a minimum.
[00:51:36] Speaker A: Very good.
[00:51:38] Speaker C: And I think that the other thing about the WHI that we learned is that formulation matters.
You know, in the WHI, which was over 20 years ago, 2002, the primary hormone replacement that was used was prempro, which was the first hormone replacement therapy. But so prempro is a synthetic estrogen from horse urine, and it's an oral medication.
We don't use Prempro very often anymore, but some people do, but it's not ideal.
We know now that transdermal estrogen versus oral estrogen has a less risk for blood clots, such as stroke and VT El, or deep vein thrombosis. So, you know, more modern prescribers of hormone replacement therapy tend to go the transdermal route to decrease that risk. That was seen increased in the WHI, and it was really linked to the oral synthetic estrogen component of that hormone replacement. So formulation matters, route does matter. It doesn't mean you can't take oral estrogen. You can, but it does have a higher risk for stroke and for venous thrombosis versus transdermal.
[00:52:54] Speaker A: That's good. Doctor Casanova, you mentioned that there is a connection between cardiovascular disease and a loss of estrogen. We know that heart disease is the leading cause of death in women, contributing to one in five female deaths in the United States. According to the CDC, while women can develop heart disease at any age, the risk increases significantly after menopause, likely due to hormonal changes.
[00:53:23] Speaker B: As doctor Mandela was alluded to, we have estrogen receptors everywhere, right? So we know that after menopause without estrogen, you know, our lipid profile is adversely affected. So our good cholesterol, the hdl cholesterol, tends to drop, and our ldl, our bad cholesterol tends to rise. We do know that women who take estrogen can increase their hdl, which can be beneficial for cardiovascular disease. We shouldn't use hormone replacement to primarily prevent cardiovascular disease. In other words, if I have a woman who has no vasomotor symptoms, no other menopausal issues, and they come in and they say, I want you to give me estrogen because I want to reduce my risk of heart disease. I mean, that's not the primary indication for it. We might recommend other things like diet and a cholesterol lowering medicine, such and such. But yes, in that certain age group between 50 and 60, I think it can be beneficial in preventing heart disease.
[00:54:28] Speaker A: Okay. All right, let's talk about bioidentical hormone replacement.
[00:54:35] Speaker B: Bio identical is not a medical term. It's a marketing term.
[00:54:41] Speaker A: Wow.
[00:54:41] Speaker C: Okay.
[00:54:42] Speaker B: So we have to be very cautious when people are suggesting that you need, your body needs bio identical. And what exactly does that mean? I think for most people, it means, well, I want the same hormone that's similar to what I'm making in my body.
[00:55:06] Speaker A: Is that possible?
[00:55:07] Speaker B: Yes, it is possible. It is possible. So I will have women come in and say, well, I don't want any of that stuff that's synthesized in the lab. I want the natural estrogen. I say, oh, hmm. Well, I. Nobody has the estrogen tree outside in the backyard because all of our medications are synthesized.
[00:55:26] Speaker A: Right?
[00:55:26] Speaker B: So the medications that we as menopause practitioners and gynecologists recommend are FDA approved compounds.
[00:55:34] Speaker A: Okay.
[00:55:34] Speaker B: And they can be bioidentical estradiol. Doctor Medella had mentioned the different types of estrogen. Estrone. Estradiol. So estradiol is bio identical. It's the same estrogen that our ovaries make. Prempro is conjugated equine estrogens. Our body doesn't make that.
So I guess if you want to say, well, I want the natural one, you could consider estradiol natural. And we do have FDA approved bio identical hormones. We have prometrium, which is micronized progesterone, similar to what our body makes.
But if it's FDA approved, we know what that dose, I can tell you, I know what this dose does. I know what this dose doesn't do. I can guess the side effects that you might have and the risks that you might have. The compounded, bio identical hormones that people are looking into are not FDA approved. They're not regulated.
So there's nobody looking over the shoulder of the compounding pharmacy to say, hey, you said there was 3 grams of that in that medication? Well, nobody's checking to make sure that that's what's in there. So they may be safe, but we just don't have the data and the science behind it. So.
And I'm not saying that again that they're unsafe. We just don't know. So I think as women consumers of the medical medicines, we should look for what we know is safe and effective and that we have scientific data to back that up.
[00:57:25] Speaker A: Absolutely.
[00:57:27] Speaker C: Pellet therapy is kind of the rage these days. That's an example of a compounded, bio identical hormone replacement therapy. The problem with pellet therapy, and I don't know if women realize this, once that pellet is in, it's in, and it stays in for up to three months. But if the dosing is incorrect, there's no way to take that pellet out.
I saw a woman in the office once who had pellet therapy over a year ago, and her estrogen levels. Her estrogen estrogen levels were in the hundreds.
And she was having migraine headaches. She was completely symptomatic. So not saying that all women that have pellet therapy will get the supraphysiologic or abnormal dose, but the problem, once the pellet is in, it's in. You cannot take it out. And like doctor Casanova said, these dosages aren't regulated. They're customized. And so the safety is really the big concern here, because if you have too much estrogen and not enough progesterone, that unopposed estrogen puts you at risk for breast cancer. It puts you at risk for endometrial cancer. So the safety is really the concern with some of the compounded medications. And there's some good compounding pharmacies out there. There is a place for compounding pharmacies. So for people that have certain allergies. So progesterone, which the prometrium that doctor Casanella was talking about is, is made in a peanut oil well. People with peanut allergies can't take it. So you can get it through a compounding pharmacy, which puts it in a suspended fluid that doesn't have any tree nut in it. So, I mean, they can customize things like that. So there is definitely a place for compounding pharmacies. But I think when it comes to hormone replacement therapy, you really have to tread caution because of the concerns of the dosing and the safety, since they're not FDA regulated.
[00:59:16] Speaker A: Absolutely. That is good information.
[00:59:19] Speaker D: And that's why we really would love for women, if they're experiencing perimenopausal symptoms or menopausal symptoms. We really would love for them to come in and speak to us with a dedicated visit where we can go over all these areas of their life, and then we can tailor our recommendations to what their goals are, what symptoms are bothering them the most. And as we were mentioning, we also can, we can prescribe bioidentical hormones for you that are FDA approved, and we can work with you to adjust the levels of those to try to match what's going to help you the most with your health goals. So we really are happy to help with that. We'd love to help with that. That's obviously one of our passion areas.
[01:00:00] Speaker C: I think the reason why we're all here today and why this platform and this discussion is so important is because women have this critical period where they can change the trajectory of their health and perimenopause and menopause is that period.
And hormone replacement therapy is only part of the solution. I think this is where we really need to hone in on lifestyle.
[01:00:26] Speaker A: Absolutely.
[01:00:27] Speaker C: Because of all the metabolic changes that are occurring at this stage of life. And if you can't change that component, and those components being your diet, your exercise, your sleep, your stress management, hormone replacement therapy isn't going to do anything for you. It's not going to work optimally. Your cells aren't going to work optimally. I mean, you don't have to end up in a nursing home. You don't have to have dementia, you don't have to have a heart attack. And women need to realize that they have more control over their health than they realize.
I think we've seen too many of our loved ones go through those things, and menopause is inevitable, but chronic disease is not. And that's why it's important that we really focus on the lifestyle component of perimenopause and menopause and just general health. We have more control over it than we realize. I think it's just a matter of education, a matter of motivation, and the awareness that we have the ability to change our future health and our lifespan and our health span.
[01:01:33] Speaker A: You are not alone.
Conversations like these are empowering and normalize what women are going through, and there's help out there. So thank you all for your time, taking time out of your busy schedules to join me to have the conversation. This is how we help to educate and support. Thank you to Doctor Casanova, Doctor Lunsford and doctor Modelo for sharing such valuable information.
And to all of our listeners, thank you for listening. Share this with your friends and women in your life. To learn more about perimenopause, menopause and supportive services throughout this phase of your life, visit us
[email protected].
menopause thank you for joining us for this special edition of the Healthy Up High Podcast. I hope our discussion today has shed light on perimenopause and menopause, providing you with practical advice and reassurance. Remember, you are not alone on this journey. Support is available and knowledge is power. If you have any questions or need further resources, don't hesitate to reach out. Until next time, take care of yourself and stay healthy.
